Brain Training Memory Assessment Form
Please complete this form to assess your memory performance as part of your brain training program.
Full Name
*
First Name
Last Name
Age
*
How would you rate your overall memory ability?
*
1
2
3
4
5
How often do you forget where you placed everyday items (e.g., keys, phone)?
*
Never
Rarely
Sometimes
Often
Always
Indicate how much you agree with the following statements:
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I easily remember new information.
1
2
3
4
5
I can recall details from conversations.
6
7
8
9
10
I remember tasks I need to complete.
11
12
13
14
15
I quickly recognize familiar faces.
16
17
18
19
20
How long can you remember a short list of words (e.g., shopping list) without writing it down?
*
Less than 1 minute
1–5 minutes
5–15 minutes
More than 15 minutes
How often do you forget appointments or planned activities?
*
Never
Rarely
Sometimes
Often
Always
How would you rate your ability to concentrate during memory tasks?
*
1
2
3
4
5
What strategies do you use to help remember important information?
Please share any additional comments or observations about your memory performance.
Submit Assessment
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